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DMAS offers a web-based Internet option (ARS) to access information regarding Medicaid or FAMIS eligibility, claims status, check status, service limits, prior authorization, and pharmacy prescriber identification. The website address the use to enroll for access to this system is http://virginia.fhsc.com. The Medical voice response system will provide the same information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.

Original Reference Number/ICN - Enter the claim reference number/ICNof the paid claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted. Only one claim can be adjusted on each CMS-1500 (08-05) submitted as an Adjustment Invoice. (Each line under Locator 24 is one claim.)

Please complete second/third claim using the same billing instructions as the first. Please provide a cover letter explaining this claim is the second or third ambulance claim for the same day service. Please attach cover letter on top of second claim with attachments and mail to:

Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.

All air ambulance claims are reviewed for medical necessity of using an emergency air ambulance. Claims submitted that do not establish air ambulance medical necessity will be paid at DMAS emergency ground ambulance rates.

In certain cases, the air ambulance provider may not agree with claim being paid at ground rate. The air ambulance provider can request the claim be reconsidered if the original claim was missing attachments or other medical information. For reconsideration please write a brief description or explanation on why the claim needs to be reconsidered.

Please mail the letter, a new original CMS 1500 with attachment to:

DMAS

Transportation Unit, Suite 1300

600 East Broad Street

Richmond, Virginia 23219

If reconsideration is denied, then please use the formal appeal process.

Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.

Block 22: Paid by Carrier Other Than Medicare- Enter the payment received from the primary carrier (other than Medicare). If Code 3 is marked in Block 7, enter an amount in this block. (Do not include Medicare payments.)

Medicaid reimburses providers for the coinsurance and deductible amounts on Medicare claims for Medicaid recipients who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid

Use the same CPT/HPCS codes that were billed to Medicare (this means using the two code system)